Nursing Ethics.ppt

By
Ayelign Mengesha
(Ass’t prof in adult health
nursing)
1
Ethico-legal & theoretical
foundation in nursing

Morality is the differentiation of intentions, decisions
and actions between those that are distinguished as
proper (right) and those that are improper (wrong).
Morality can be a body of standards or principles
derived from a code of conduct from a
particular philosophy, religion or culture, or it can
derive from a standard that a person believes should
be universal.
It usually refers to private, personal standards of
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Unit I. Moral Foundations of Nursing

UNIT I. MORAL FOUNDATION OF NURSING…
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Clues to the Moral Nature of Situation
1.An aroused conscience or an awareness of feelings, such as
guilt, hope, or shame
2.Tendency to respond to the situation with words such as
ought, should, right, wrong, good and bad.
Moral Development
The process of learning to tell the difference between right
and wrong, and of learning what ought and ought not to
be done.
involves a process whereby a person undergoes ever closer
approximations to the traditional ethics ideal of self-
governing individual (Kohlberg,1981)
a complex process that begins in childhood and continues
throughout life

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Moral development –is an evolving, continuous, and
dynamic process that moves along a continuum from
forming a world view and a value system.
 For Kohlberg, the core of morality is justice.
 For Rest (1984), there is more to moral development than the
development of moral judgment. According to him, moral
behavior is the end product of four distinct psychological
processes: moral sensitivity, moral judgment, moral motivation
and moral character.
Theories of Moral Development
1.Lawrence Kohlberg’s Theory (1969) emphasizes rights and formal
reasoning
2. Carol Giligan’s Theory (1982) emphasizes care and responsibility.

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1. Kohlberg’s Theory of Moral Development
Kohlberg theorizes a cognitive development process that is
sequential in nature with progression through levels &
stages.
A. Pre-conventional Level
 Moral decisions made at this level are simply in response to
some threat of punishment.
 Good-bad, right-wrong labels have meaning but are defined
only in reference to a self-centered reward-and-punishment
system
 Person has no concept of the underlying moral code
informing the decision of good-bad or right-wrong.
B. Conventional Level
People begin to internalize their view of themselves in response to
something more meaningful and interpersonal.
There’s a desire to find approval from others.
Conformity to expected social and religious mores.
 Not all people develop beyond the conventional level of
moral development.

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C. Post-conventional Level: A morally mature individual, one of the
few to reach moral completeness.
 An autonomous thinker who strives for a moral code beyond issues
of authority and reverence.
 The morally mature individual’s actions are based on principles of
justice and respect for the dignity of all humankind and not just on
principles of responsibility, duty, or self-edification( Kohlberg, 1971).
2. Carol Gilligan’s Theory of Moral Development
 Gilligan developed her own stages of moral
development with the idea that women make moral
and ethical decision based on how they will affect
others in mind.
 She followed Kohlberg's stages of preconventional,
conventional, and postconventional morality, but she
based these upon her research with women rather than
men.

 Preconventional morality – This stage revolves around self-
interest and survival. When a conflict arises between the needs
of oneself and the needs of others, a woman will choose her own
needs first.
 Transition one: During this transition, a woman realizes her
responsibility for others and that she could have previously
been thinking selfishly.
 Conventional morality – This stage revolves around being
selfless and prioritizing care for others. A woman realizes the
needs of others and cares for them over herself, leading to self-
sacrifice.
 Transition two: During this transition, a woman realizes her
needs are just as important as the needs of others. She realizes
she must balance the needs of herself and the needs of others.
This is a shift from "goodness" to "truth" as she honestly
assesses the needs of each, not just as a responsibility.
 Postconventional morality – This stage involves women paying
attention to how their actions affect others, and taking

UNIT I. MORAL FOUNDATION OF NURSING...
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Solving moral/ethical dilemmas
The Four-Component Model of Morality (Rest,1984)
1. Moral sensitivity: Is the awareness of how our actions affect other
people
2.Moral judgment: Concerned with which action is more morally just
or right (or morally justifiable) than other actions.
3. Moral motivation: Involves the importance a person gives to moral
values in competition with other values in making moral judgments.
4. Moral character: Involves ego strength, perseverance, backbone,
toughness, strength of conviction , and courage.
 A certain amount of each of psychological roughness and strong
character is necessary to carry out a moral action.
 If a deficiency occurs in any of the for components of morality, moral
failure results (Rest, 1984).

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Value Formation and Moral Development
Values
 Things of social life (ideals, customs and institutions) toward
which people have an affective regard.
 Personal beliefs about worth/usefulness of something which can
act as a standard to guide behaviors.
The Nature of Values
 Arise from needs or wants (Glen, 1999)
 Derived from many sources such as person’s culture, family, peer
group or work environment.
 Can be expressed in language or standards of conduct that a
person endorses or tries to maintain.
 Are organized into a system that has meaning to the individual
 Can be non-moral or moral values
 Non-moral values-are values not based on moral
considerations and the significant moral interests of people.
Example: style and decorum
 Moral values –are of a distinctively moral nature in that they
derive from significant moral interests of the people have in
upholding such things as human life.

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 Value system --is an entire framework on which actions are based.
A refined value system and world view – can serve professionals as
they deal with the meaning of life and its many choices.
 World view: a particular philosophy of life or conception
of the world
provides a cohesive model for life;
encourages personal responsibility for the living of that life
prepares one for making ethical choices
Types of Values
1. Cultural Values --are the accepted and dominant standards of a
particular cultural group.
2. Religious Values (often confused with cultural values and beliefs
and/or the culture of a people) are, like ethics, the product of culture
and history from which they have emerged.
3. Personal Values- are formed from individual beliefs, attitudes,
standards and ideals that guide behavior and how a person
experiences life.
4. Professional Values- relate to the ultimate standards that have been
agreed to, and are expected to be upheld by a professional group
(Johnstone1998)

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Value Conflicts
 Both moral and non-moral values can easily conflict with one another
and with patients’ rights and nurses’ professional duties.
 Personal values may conflict with professional values, which in turn
may conflict with cultural values.
 The nurse’s value of doing good to the patient might conflict with her
value of honoring the patient’s choices or his or her right to make
such choices.
 The nurse’s value of giving safe medication dosages might conflict
with the patient’s value of relief from pain and the perceived
professional duty to relieve suffering.
 The elderly resident’s value of personal liberty and being able to walk
around an aged care facility at any time, both day and night, might
conflict with the institution’s value of client safety, achieved by
surveillance and security locks on all public thoroughfares leading to
and from the facility.

Value Conflicts …
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In each of these situations, the nurse must identify the
following :
 The values involved
 The relevance of rights claimed and their corresponding duties and
 Where a conflict between values, rights and/or duties may be
occurring.
 The nurse must then make a decision based on which values are most
important and which rights claims are most warranted and deserving of
respect.
 When moral values, rights claims, and associated duties are involved,
resolving value conflict becomes a complex and sometimes perplexing
ethical decision-making process.

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Approaches to Values Formation and Moral
Development
1.Examining Value Systems
 To become a competent professional in every dimension
of nursing care, nurses must examine their own system of
values and commit themselves to a virtuous value system.
A. Values Clarification Processes
deliberately question the moral/ethical correctness or
“rightness” of a decision.
an important part of the valuing-clarifying process because
it emphasizes affective thinking and behavior-motivated
choice
Fundamental Processes of Values Clarification
--involve the use of rational thought and awareness to
understand, examine and scrutinize the values.

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Approaches for Values Clarification
 Real or contrived/fake dilemmas
 Group or individual work
 Self-analyses or interview
 Other methods that free individuals to examine and embrace their values
Guidelines for Values Clarification
1.Select or create an ethical/moral dilemma that participants will emotionally
relate to and not see as fictitious to their practice.
2. Focus on clarifying individual values that should emerge from the process,
regardless of the process used for clarification. Lively discussions about
what should be done do not substitute for a deliberative focus on one’s own
personal values.
3. Write or list personal values that emerge. This helps to make values explicit,
clarifying what the values are and also provides a forum for examining how
and why the values change.
CLARIFICATION OF VALUES often is an emotionally charged activity
involving deeply held personal beliefs.

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General Questions for Values Clarification
 What outcome would I like to see ?, What would I do ?, How do I
feel about this ?
 What is guiding my potential actions ? Feelings ?
 What would need to change about the context for to act or feel
differently?
 Are there any alternatives in this situation , and how viable are
they ?
 How proud do I feel about my choices ? Would I affirm them to
others?
 Does there seem to a hierarchy of choices ?
B. Values Analysis
 Seeks to more objectively understand and analyze the values
operating in a situation.
 Participants are required to recognize their value structure
objectively and critically.
 Participants strive to gain clarity on an issue, examine various
points of view factually and logically, and examine different

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Guiding Questions For Value Analysis
 What are the ethical/moral issues ?
 What ethical/moral decisions are being made ?
 What ethical/moral bases are operating to guide those
decisions ?
 How strong are the arguments? The counterarguments ?
 Is more evidence needed to justify a decision ? What sort ?
 Are there any inconsistencies related to ethical decisions
being made ?
 What evidence do we need to know whether the decisions

Approaches to Values Formation and Moral
Development…
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2. Learning Right and Wrong
3. Understanding Moral Development Theory
4. Moving Toward Maturity
 The rightness or wrongness of the complex and
confounding health care decisions being made
today depends on the level of moral
development of those professionals entrusted
with the tough decisions.

Essential Nursing Values and Behaviors
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Essential Values Attitudes and Personal Professional
Behaviors
Qualities
Altruism-concern Caring, commitment, compassion Gives full attention to the client
when giving
for others’ welfare generosity, perseverance care; assists other personnel in
providing care
when they are unable to do so
Express concern about social
trends and issues
that have health care implications.
Equality-having the Acceptance, assertiveness, Provides nursing care based on
the individual’s
same rights, privileges fairness, self-esteem needs irrespective of personal
characteristics
or status tolerance Interacts with other providers in a
non-
discriminatory manner.
Justice-upholding Courage, integrity Acts as health care advocate
moral and legal morality, objectivity Allocates resources fairly
principles Reports incompetent, unethical and illegal
practices objectively and factually

Essential Nursing Values and Behaviors…
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Essential Values Attitudes and Personal Professional
Behaviors
Qualities
Esthetics –qualities of Appreciation, creativity Expresses ideas about the improvement
of access
objects, events, and imagination, sensitivity to nursing and health care.
persons that provide Adapts the environment so that it is
pleasing to
satisfaction the client.
Creates a pleasant work environment
for self
and others
Presents self in a manner that promotes
a positive
image of nursing
Human dignity- Consideration, empathy, Safeguards the individual rights to
privacy
inherent worth and humaneness, kindness, Addresses individuals as they prefer to
be addressed
uniqueness of respectfulness, trust Maintains confidentiality of clients and
staff
person Treats others with respect, regardless
of background

UNIT II. CODE OF ETHICS FOR NURSES
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 Ethics is the study of what is right or wrong in human conduct.
This is a branch of Philosophy which studies moral principles
(Cherry,2005).
 the application of the processes and theories of moral philosophy to
real situation(Jones,2000)
 concerned with the basic principles and concepts that guide human
beings in thought and action, and which underlie their
values(Jones,2000).
Bioethics
 Bioethics is a branch of ethics which is concerned with the
research and application of biology. Typically, bioethics weighs
issues within medical advancements, health science, and
other medical fields such as reproduction and genetics.
 the study of ethical problems resulting from scientific advances and
is a response to contemporary advances in health care.
Nursing Ethics --is part of the broader called bioethics which consists
of a system of principles concerning the actions of the nurse in

UNIT II. CODE OF ETHICS FOR NURSES…
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Code of Ethics
 a written list of a profession’s values and standards of conduct which provides a
framework for decision-making for the profession (Catalano,2003)
 ethical principles that govern a particular profession.
 presented in general statements and do not give specific answers to every
possible ethical dilemma that might arise.
 usually have higher requirements than legal standards, and they are never lower
than the legal standards of the profession.
 should be reviewed periodically to reflect necessary changes of the profession
and society as a whole.
 Codes of nursing ethics
 makes the professional values of nursing public and indicate the values central
to professional education programs.
 is a guide for “carrying out nursing responsibilities in a manner
consistent with quality in nursing care and the ethical obligations of the
profession.”
 Professional codes: have a function of self-regulation and are regarded as
system of rules and principles by which a specific profession is expected to

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Purposes of Nursing Codes of Ethics /function
1. Inform the public about the minimum standards of the
profession and help them understand professional nursing
conduct.
2. Provide a sign of the profession’s commitment to the public
it serves.
3. Outline the major ethical considerations of the profession.
4. Provide general guidelines for professional behavior.
5. Guide the profession in self-regulations.
6. Remind nurses of the special responsibility they assume
when caring for the sick.
1. The International Council of Nurses (ICN) Code of Ethics
of Nurses
 was first adopted by the ICN in 1953.
 has been revised and reaffirmed at various times

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The ICN Code of Ethics for Nurses
 The fundamental responsibility of the nurse is fourfold: to
promote health, to prevent illness, to restore health, and to alleviate
suffering.
 The need for nursing is universal. Inherent in nursing is respect for
life, dignity and rights of man.
 It is unrestricted by considerations of nationality, race, creed, color,
age, sex, politics or social status.
 Nurses render health services to the individual, the family, and the
community and coordinate their services with those of related groups.

The ICN Code of Ethics for Nurses…
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Nurses and people
The nurse’s primary professional responsibility is to
people requiring care.
In providing nursing care, the nurse promotes an
environment in which the human rights, values, customs
and spiritual beliefs of the individual, family and
community are respected.
 The nurse ensures that the individual receives sufficient
information on which to base consent for care and
related treatment.
 The nurse holds in confidence personal information and
uses judgment on sharing this information.
 The nurse shares with society the responsibility for
initiating and supporting action to meet the health and
social needs of the public, in particular those of
vulnerable populations.

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Nurses and practice
 The nurse carries personal responsibility and accountability for
nursing practice and for maintaining competence by continual
learning.
 The nurse maintains a standard personal health such that the
ability to provide care is not compromised.
 The nurse uses judgment regarding individual competence when
accepting and delegating responsibility.
 The nurse at all times maintains standards of personal conduct
which reflect well on the profession and enhance public
confidence.
 The nurse, in providing care, ensures that the use of technology
and scientific advances are compatible with safety, dignity and
rights of people.
Nurses and the profession
 The nurse assumes the major role in determining and
implementing acceptable standards of clinical nursing practice,
management, research and education.
 The nurse is active in developing a core research-based

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Nurses and coworkers
The nurse sustains a co-operative relationship with
coworkers in nursing and other fields.
The nurse takes appropriate action to safeguard
individuals when their care is endangered by a
coworker or any other person.
2. The American Nurses’ Association (ANA) Code of
Ethics
provides a framework to aid nurses in resolving
ethical dilemmas and in analysis and decision-
making in day-to-day work settings.
has been acknowledged by other health-care
professions as one of the most complete.

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The American Nurses’ Association Code of Ethics
1.The nurse, in all professional relationships practices with
compassion and respect for the inherent dignity, worth
and uniqueness of every individual, unrestricted by
consideration of social or economic status, personal
attributes or nature of health problems.
2. The nurse’s primary commitment is to the patient,
whether an individual, family, group or community.
3.The nurse promotes, advocates, and strives to protect
the health , safety, and rights of the patient.
4. The nurse is responsible and accountable for individual
nursing practice and determines the appropriate
delegation of tasks consistent with the nurses’ obligation
to provide optimum patient care.
5. The nurse owes the same duties to self as to others
including the responsibility to preserve integrity and
safety, to maintain competence, and to continue

The American Nurses’ Association Code of Ethics…
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6. The nurse participates in establishing, maintaining, and
improving health care environments and conditions of
employment conducive to the provision of quality health care
and consistent with the values of the profession through
individual and collective action.
7. The nurse participates in the advancement of the profession
through contributions to practice, education, administration,
and knowledge development.
8. The nurse collaborates with other health professionals and
the public in promoting community, national, and international
efforts to meet health needs.
9. The profession of nursing, as represented by associations
and their members, is responsible for articulating nursing
values, for maintaining the integrity of the profession and its
practice, and for shaping social policy.

UNIT III. Ethical Principles And Case Studies In
Bioethics
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Ethical Principles
Ethical principles in nursing are standards and regulations
that guide nurses on how to effectively carry out their
responsibilities and make sure their behaviour at work is
consistent with professional values in nursing.
1. Autonomy
the right of a person to make one’s own decisions and direct
one’s life.
the right of self-determination, independence and freedom.
is not an absolute right, as with most rights. Limitations can be
imposed on it, such as when one individual’s autonomy
interferes with another individual’s rights, health or well-being.
2. Beneficence –the responsibility of doing good.
Good care requires that the health care provider approach the
patient in a holistic manner.
Difficulty sometimes arises in implementing the principle of

UNIT III. Ethical Principles And Case Studies In Bioethics…
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3. Fidelity
 is the individual’s obligation to be faithful to
commitments made to self and others.
 the main support for the concept of accountability,
although conflicts in fidelity might arise because of
obligations owed to different individuals or groups.
 includes the professional’s faithfulness or loyalty to
agreements and
responsibilities accepted as part of the practice of the
profession.
4. Justice
 is the obligation to be fair to all people.
 the concept is often expanded to what is called
distributive justice.
 Distributive justice-specifically states that individuals have the
right to be treated equally regardless of race, sex, marital
status, medical diagnosis, social standing, economic level, or
religious belief.

UNIT III. Ethical Principles And Case Studies In Bioethics
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5. Nonmaleficence
 the responsibility of avoiding harm to the person; the
requirement that health care providers do no harm to their
patients, either intentionally or unintentionally.
 is the opposite side of the coin of beneficence.
 By extension, the principle of nonmaleficence also requires that health
care providers protect from harm those who cannot protect themselves.
This protection from harm is particularly evident in such
groups as children ,the mentally incompetent, the
unconscious, and those who are too weak or debilitated to
protect themselves.
6. Veracity (truthfulness)
 requires that the health care provider tell the truth and not intentionally
deceive or misled patients.
 As with other rights and obligations, there are limitations to this
principle.

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Strategies to Enhance Ethical Nursing Practice
 Become aware of your own values and the ethical
aspects of nursing.
 Be familiar with nursing codes of ethics.
 Respect the values, opinions and responsibilities of
other health care professionals that may be different
from your own.
 Participate in or establish ethics rounds.
 Ethics rounds using hypothetical or real cases incorporate
the traditional teaching approach for clinical rounds, but
focus on the ethical dimensions of client care rather than
the client’s clinical diagnosis and treatment.
 Strive for collaborative practice in which nurses
function effectively with other health care
professionals.

Bioethics…
Nurse’s Bill of Rights
1. The right to be treated with respect.
2. The right to a reasonable work load.
3. The right to an equitable wage.
4. The right to set your own priorities.
5. The right to ask for what you want.
6. The right to refuse without making excuses of
feeling guilty.
7. The right to make mistakes and be responsible
for them.
8. The right to give and receive information as a
professional.
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34
Facility Liability: Employment Issues
 Facility liability arises from two separate and distinct sources. The
first comes from malpractice committed by medical staff and the
second arises from the negligence of administrative staff.
 Vicarious Liability: is the legal doctrine often cited when dealing with
facility liability.
Four Bases for Facility Liability
1. Respondeat superior
2. Ostensible authority
3. Corporate negligence
4. Employment liability
A. Respondeat Superior – means “Let the master answer.” If the nurse
breaches a duty or standard of care owed to the patient and causes
injury, the employer may be held legally liable under this doctrine.
Elements of Respondeat Superior
1. Act or omission of the employee
2. Occurs during employment relationship
3. Negligent act occurred within the scope of employment

Bioethics…
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Liablity
 Under the principles of vicarious liability and the doctrine of
respondeat Superior, the nurse, as well as his/her employer
can be held liable.
 The employer may be named in a suit with or without the
employee and may be held liable because of the employer-
employee relationship.
Forms of vicarious liability theory
Borrowed Servant Doctrine
The doctrine says that if someone “borrows an employee
of someone else, the borrower is legally responsible for
the “servant’s” or” employee’s” acts.
Captain of the Ship Doctrine
Also a form of vicarious liability
Doctrine which holds that if a person supervises or
controls another, he or she is legally responsible for that

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B. Ostensible Authority or Agency
A facility is liable for the negligence of an
independent contractor if the patient has a rational
basis to believe that the independent contractor is a
facility employee.
Facilities may be held liable for the acts of
independent contracting nurses, just as they are
found liable for the wrongful acts of physicians who
are independent contractors.

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Elements of Ostensible Authority
1. Subjective
 When a patient looks to the facility for his or her treatment and
is treated by medical personnel who are ostensible agents of
the facility, the facility is held liable.
2. Inherent Function
 One that exists in and is inseparable from the hospital.
3. Reliance
 The facility is held liable if the patient relies on the facility’s
judgment (e.g. choosing to be admitted to the hospital for
surgery rather than another) but is injured because of
something that the facility did or omitted doing.
4. Control
 In certain circumstances, a facility may be liable for an
independent contractor if a certain degree of control is
exercised by the facility over the independent contractor.

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Factors to Identify Whether or Not Control Exists
1. The extent to which the employer determines the details of
the work
2. The kind of occupation
3. The customs of the industry’
4. Whether the work is generally supervised by the employer
5. Who supplies the place to work
6. The method of payment
C. Corporate Negligence
Two Separate and Independent Facility
Responsibilities Under the Doctrine of
Corporate Negligence
1. The responsibility to hire qualified employees
2. The responsibility to monitor and supervise their

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 Instances of Failure When the Facility is Charged of
Negligent Hiring
 Failure to :
Check references.
Perform criminal checks on applicants.
Confirm license status.
Determine skill and educational levels.
 If a facility knows that an employee has harmed a patient but
does not terminate that employee, it risks liability for failure to
fire should that employee injure another patient.
D. Employment Law Liability
 Employment Agreements
Employment at Will permits either the employer or the
employee to terminate employment without cause or notice.

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Contractual employees
 any reason for termination before the expiration of contract
may be considered unlawful.
 the only way to terminate a contractual employee is specified
in the contract.
 Reasons for Termination If the Contract does Not Provide the
Basis
1. At the expiration of the amount of time specified in the contract
2. When the employee breaches the terms of the contract.
Contract Arising After Employment
 Handbooks and Personnel and Policy Manuals- can create
an employment contract.
 Statements in employee manuals or company policies
 can be contractually binding
 can alter an underlying employment at-will status

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Independent Consideration
 When an employment contract or the policies and
procedures appear to provide for termination at will, if an
employer gives the employee extra pr independent
consideration (1.e. extra salary or benefits ) beyond that what
is stated in the contract or in the policies and procedures, that
contract may not be terminable at will.
Evaluating Employee Performance
 Conducting periodic evaluation may lead to a just cause
requirement for
termination.
Terminating Problem Employees
 How an employee is handled during the termination process,
regarding
reasons for the termination and conveying the news, can make

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Standards for Dismissal
1. Depressed market conditions
2. Financial needs for the business to reorganize and
relocate operations
3. Open defiance(violation) and insubordination
4. Fighting
5. Excessive absenteeism
Post Termination
 The issue of references: To prevent potential liability for
defamation or negligence on giving out or serving as a
reference to a terminated employee, the employer should only
reveal the information that the employee worked for a specific
period of time and performed a particular type of work.
 Conditional Privilege: Nondefamatory statements of employer
concerning the character of former employees if directed to a prospective
employer.

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Loss of Conditional Privilege
 occurs if the employee can not prove that the employer
recklessly
disseminates statements, disregards truth or falsifies
information, fails to
verify information, or where it is practical, fails to safeguard
against error.
Negligence
 can be claimed by the employee for damages incurred in
addition to
defamation against the previous employer for not exercising
due care in
providing references it gives voluntarily.
Discrimination and Harassment

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Sexual Harassment
 Concerned with the misuse of power and control over others in
“lower “positions of the power structure in both academic and
clinical settings.
 can be homosexual or heterosexual and is unlawful if submission
to it meets the following conditions:
a) is a condition of employment
b) interferes with performance
c) is the basis for employment decision
d) creates a hostile and intimidating work environment
Two Types of Sexual Harassment
1. Quid pro quo- claims stem from implicit request for sexual favors
and from requests for sexual favors that are used as a condition for
employment decisions such as promotions.
2. Hostile Work Environment: Offensive behavior creates a
hostile or intimidating work environment which interferes with the work

Bioethics…
Reading assignment
Justice and Allocation of Scarce Resources in
health care settings
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Introduction
 The branch of philosophy concerned with principles that allow
us to make decisions about what is right and wrong is called
ethics or moral philosophy.
 Bioethics is specifically concerned with moral principles and
decisions in the context of medical practice, policy, and
research.
 Moral difficulties connected with health care are so complex
and important that they require special attention.
 Nursing ethics gives them this attention, but it remains a part
of the discipline of ethics.
 Thus, if we are to answer the question as to whether there are
any rules or principles to use when making moral decisions in
the medical context, we must turn to general ethical theories
and to a consideration of moral principles that have been
46
UNIT IV. FOUNDATION OF BIOETHICS

UNIT IV. FOUNDATION OF BIOETHICS …
47
Major Ethical Theories
1. Teleological (Consequence-based) Theory
 is a theory according to which the rightness of an act is
determined by its outcome.
 The word teleological comes from Greek telos, meaning end
or goal, and logos meaning science.
 Thus, teleological theories focus on the consequences of
actions; in other words, this theorizes that our actions
being morally right or wrong depends on the good or evil
generated.
 Thus, in teleological ethics, consequences drive the moral
decision. For example, most people believe that lying is
wrong, but if telling a lie would do no harm and help to make
a person happy or save someone, this action would be right
in teleological ethics.

2. Utilitarianism
Is a theory of morality that advocates actions that
foster happiness and oppose actions that cause
unhappiness.
Is one form of consequence-based theory
It promotes "the greatest amount of good for the
greatest number of people."
is a reason-based approach to determining right
and wrong, but it has limitations.
It does not account for things like feelings and
emotions, culture, or justice.
Used in making decisions about the funding and
delivery of health care.
48

3. Principles-based (deontological theories) -
Emphasizes individual rights, duties and obligations.
Deon is the Greek word for duty, and as the term
suggests, deontological theory considers duty to be
the central issue.
Deontologists believe that what is good in the world
stems from people doing their duty.
 The morality of an action is determined not by its
consequences but by whether it is done according to an
impartial, objective principle.
 Deontological is an approach to ethics that focuses on the
rightness or wrongness of actions themselves, instead of
examining its consequences or any other considerations.
 Here, action drives the moral decision.

UNIT V IV. FOUNDATION OF BIOETHICS …
Also, this theory avoids subjectivity and uncertainty.
It is based on the belief that there are standards for the
ethical choices and judgments that an individual makes.
 The standards are fixed and do not change when the
situation changes.
 For example, suppose your friend has given you a gift, but
you hate this gift. She or he wants to know whether you
like this. If you believe that lying is always bad no matter
the consequences, you would tell the truth, i.e., that you
hate it, even if the outcome of your action bad (in this case,
50

UNIT V IV. FOUNDATION OF
BIOETHICS …
51

UNIT IV. FOUNDATION OF BIOETHICS…
52
4. Relationships-based (caring) theories
 Stress courage, generosity, commitment, and the need to
nurture and maintain relationships.
 Unlike the two preceding theories, which frame problems in
terms of justice (fairness) and formal reasoning, caring
theories judge actions according to a perspective of caring
and responsibility.
 Principles-based theories stress individual rights, but caring
theories promote the common good or the welfare of the
group

53
Moral framework
 is a particular set of rules, ideas, or beliefs which you use in
order to deal with problems or to decide what to do.
 Imagine a situation in which a frail, elderly client has made it
clear that he does not want further surgery, but the family and
surgeon insist.
 Three nurses have each decided that they will not help with
preparations for surgery and that they will work through proper
channels to try to prevent it.
 Using consequence-based reasoning, Nurse A thinks, "Surgery
will cause him more suffering; he probably will not survive it
anyway, and the family may even feel guilty later."
 Using principles-based reasoning, Nurse B thinks, "This violates
the principle of autonomy. This man has a right to decide what
happens to his body.“
 Using caring-based reasoning, Nurse C thinks, "My relationship

54
Common Areas of Negligence and Liability
Negligence and Nurses’ Liability
 Negligence is a failure to exercise appropriate and/or ethical
ruled care expected to be exercised amongst specified
circumstances.
 Hence, nursing negligence refers conduct that is
unreasonable under the circumstances or that fails to meet the
appropriate standard of care.
 Liability means legal responsibility
 A nurse is legally responsible for actions that fail to meet the
standard care or for failing to act and thereby causing harm.
Common Causes of Liability for Nurses
1. Treatment
2. Communication
3. Medication

55
Top 10 Most Common Allegations (acquisitions) in Nursing
Malpractice Claims
1. Patient falls
2. Failure to monitor
3. Failure to ensure patient safety
4. Improper performance of treatment
5. Failure to respond to patient
6. Medication error
7. Wrong dosage administered
8. Failure to follow facility procedure
9. Improper technique
10. Failure to supervise treatment
Best Ways of Avoiding Negligence
 By giving safe, high-quality nursing care
 Be aware of potential problem areas, identifying the risk areas in
individual practice
 Taking measures to minimize exposure to identified risks

56
Common Types of Patient Incidents
1.Patient Falls
Most Important Measures for Preventing Lawsuits
Assessing for fall potential (e.g. fall risk assessments) )
risks
 Fall risk screening should be conducted at every
admission to determine which patients are considered
high-risk for falling.
 Many factors can increase a patient’s risk for falling:
 Illnesses that cause weakness
 Medicines that cause dizziness
 Delirium
 New or unfamiliar environments
 Lack of activity

Some measures to prevent patient falls
 Conduct regular safety rounding
 Provide easy access to mobility aids
 Restraint
 applied to restrict patient movement in cases where the
patient may cause personal harm or harm to others.
application may lead to allegations of false
imprisonment.
Items to be Charted for a Patient with Restraint
 Ineffective alternatives that were tried prior to restraints
 Reason for restraints; describe patient’s behavior and type of restraint
used
 The time and date when restraints are applied
 The times when the patient is monitored while restraints are in place
 Patient’s response to restraints
 How facility policy and procedures are followed with regard to how
57

58
3. Medication Errors
Most Commonly Reported Types of Medication Errors
(US Pharamcopeia)
1. Improper dose and quantity errors
2. Unauthorized drug errors (e.g. administration of the wrong
medication)
3. Omission errors (medications were not administered)
 The key factors contributing to these errors are heavier
workloads and distractions.
4. Burns: Nurses must be particularly alert to the risk of burns
when the patient has decreased sensitivity to heat or is
unable to communicate discomfort.
5. Equipment injuries
 The nurse’s duty to exercise reasonable care includes a duty to
select, maintain, and use equipment properly.

59
6. Retained Foreign Objects
-are a problem primarily for operating room nurses and others who
are involved in invasive procedures in which drains, instruments,
needles, cotton balls, sponges, hemostats, or monitoring devices
are used during the surgery.
 Most cases in which a patient alleges that a foreign object was
retained involve extensive examination of the facility’s count policy
and the nurses compliance with that policy.
7. Failure to Monitor Adequately
-arises in clinical areas where the patient’s condition changes
rapidly, such as in the postanesthesia recovery unit, the intensive
care unit ,or the labor and delivery unit.
8. Failure to Take Appropriate Nursing Action
Some cases involve simply failing to recognize that a patient’s
needs are beyond the nurse’s training or expertise; others to
involve acts of nursing incompetence that appear to be almost

UNIT IV. FOUNDATION OF BIOETHICS
60
9. Failure to Confirm Accuracy of Physician’s Orders
 When the nurse is unfamiliar with a medication or
uncomfortable with any order, treatment, or procedure, the
prudent nurse is expected to investigate further. ``
INFORMED CONSENT
 is the voluntary permission that a patient or patient’s legal
representative (who knows the risks involved) gives to the
health care provider to do something to or for that patient.
Patient’s Attributes to Make an Informed Decision and Consent
1. Ability to communicate and understand information.
2. Ability to communicate values and goals.
3. Ability to reason and deliberate about choices

61
Types of Procedures that Require Consent
1. Major invasive surgery
2. Minor invasive surgery
3. All procedures using anesthesia
4. Electroconvulsive therapy
5. Experimental treatment procedures
6. Blood and blood product transfusion
7. Radiological therapy
8. Procedures and treatments that may cause injury or
damage
A. Chemotherapy
B. Medications
C. Arteriograms
D. Myelograms

62
Capacity to Consent: Capacity is defined as the “ability
to understand the nature and effects of one’s acts.
To be effective legally, a patient consenting or refusing
medical treatment must possess the legal capacity to make
his or her own health care decisions.
Decision-making capacity: The ability to participate in one’s
care decision based on one’s ability to understand one’s
condition and surrounding situation, use relevant information
presented and communicate one’s preference and the
reason for such choice.
Health Care Agents:
Health care agent or "agent" means an adult to whom authority
to make health care decisions is delegated under a health care
proxy.
This is a person people allow to make decisions for them in case
they can’t make decisions for themselves. For example, if you

Legal documents used to designate health care
agents may be called any of the
following:(papers in the hand of HCP on behalf
of unconscious person)
1.Durable Power of Attorney in Health Care
(DPAHC)
2.Health Care Representative Form
3.Medical Durable Power of Attorney
4.Medical Power of Attorney
63

64
Types of Consent
1. Expressed consent- can be oral or written
Written consent is preferable
2. Implied consent may be presumed in emergency situations or
inferred from the patient’s actions.
Minors and Consent
A minor –is a person who is below the area of majority
according to state law (<18 age).
An emancipated minor is one who :
1. Is financially independent
2. Lives apart from his or her parents,’
3. Is married,
4. Is considered to have the same legal capacity as an adult.
Mature minor is one who the courts have determined to have
sufficient understanding of the nature and consequences of
the treatment proposed despite his or her chronological file.

65
Exceptions to Parental Consent
Some states allow minors to:
1. Consent to medical treatment for sexually transmitted
diseases, pregnancy-related medical care, physical abuse,
and substance abuse.
2. Consent in an emergency medical situation.
3. Consent if they are considered a mature or emancipated
minor.
Documenting Consent
 In the event of a lawsuit, proper documentation supports the
health care provider’s testimony regarding informed consent.
 A consent form that is not specific, but merely states that the
elements of informed consent have been discussed with the
patient, may not be sufficient to prove that the patient actually
gave informed consent.

66
Information About Informed Consent in the Medical Record
 Summary of information given to the patient
 Statement dictating that all the patient’s questions were answered
 Any response by the patient acknowledging his/her understanding of the
information provided
Information Which Should be Disclosed in Informed
Consent
1. Name of person or persons providing treatment or procedure
2. Diagnosis or suspected diagnosis of the patient
3. Conflicts of interest
4 .Nature and purpose of the proposed treatment or procedure
5. Material risks, complications, side effects, and consequences of the
proposed treatment or procedure
6. Benefits and anticipated outcome of the proposed treatment
7. Available benefits, if any
8. Consequences if the proposed treatment or procedure is refused.

67
Exceptions to Duty to Disclose
1. Waiver of right to receive information
2. Emergency
3. Medical judgment that information would be harmful to the patient (the
therapeutic privilege)
4. Obvious risk
Tips for Informed Consent for Health Care Providers
1. Have a policy on informed consent.
2 . Be honest if asked about your qualifications.
3. Physicians should check with the Board of licensure and professional
sources to determine the laws relating to informed consent.
4. Educate the patient through discussion, videotapes, literature, and
questions and answers.
5. Use plain language ; eliminate medical jargon.
6. Know the informed consent requirements related to office and surgery
procedures.
7. Discuss and educate the patient on the risks of prescription drugs and
their side effects.

68
Treatment Without Consent
 may result in a lawsuit
 An injured plaintiff may claim that the defendant (health care
provider) is liable for any of three things :
1. assault and, or battery
2. lack of informed consent
3. negligently obtaining informed consent
Assault and Battery
Assault –is an intentional act by one person that causes another person
to fear that he or she will be touched in an offensive or
injurious manner, even if no touching actually takes place.
Battery- occurs if the act results in actual physical contact or touching.
Negligently Obtained informed Consent
 Lawsuits alleging lack of consent are likely to be based on principles of
professional negligence rather than claims of assault and battery.

69
DO NOT RESUSCITATE (DNR) ORDERS
A do-not-resuscitate order, or DNR, is a legal order
written by a doctor.
It instructs health care providers not to do
cardiopulmonary resuscitation (CPR) if a person’s heart
stops or if they stop breathing.
The order is used for people who are terminally ill or who
have irreversible conditions.
A DNR does not end medical treatment
such orders do not indicate that other treatment, to
which the patient has consented, must be withheld or
terminated.
Often dilemmas result when nurses caring for the patient
attempt to address the patient’s and the family’s wishes.

70
COMMON DILEMMAS NURSES FACE REGARDING DNR
ORDERS
1. Lack of documentation in the medical records, especially the
progress notes, indicating how the DNR was made.
2. No DNR form on the chart.
3. Performing a “slow code”or “show code” for the benefit of
family members.
4. Transfer of residents: Is a DNR order accompanying a
resident when he is transferred from one facility to another
acceptable ?
5. Abandonment of care by health care personnel of patients
designated as DNRs.
6. Family conflicts over DNR orders.
7. Physicians who will not honor DNR.
8. Family does not understand the difference between a DNR

Unit V. Models of Ethical Analysis
71
Ethical dilemma
--a situation that requires an individual to make a choice
between two equally unfavorable alternatives.
 When ethical dilemmas are reduced to their elemental
aspects, conflicts
between one’s individual’s rights and those of another, or any
combination of obligations and rights conflicting usually form
the dilemma.
 By the very nature of dilemma, there is no one good solution,
and the decision made often has to be defended against those
who disagree it.
Bioethical dilemmas
are situations that pose a choice between perlexing
alternatives in the delivery of health care because of

Unit V. Models of Ethical Analysis…
72
Ethical Decision-making Process
 Provides a method for nurses to answer key questions
about ethical dilemmas and to organize their thinking in a
more logical and sequential manner.
 Also presupposes that the nurse making the decision
knows that a system of ethics exist, knows the content of
the ethical system ,and knows that the system applies to
similar decision-making problems despite multiple
variables.
 At some point, nurses need to undertake the task of
clarifying their own values if this has not been done or has
not been done recently.
Chief Goal of the Ethical Decision-making Process
To determine right from wrong in situations where clear

73
The Five-Step Ethical Decision-Making
Process
Step 1: Collect, Analyze, and Interpret the Data
 Obtain as much information as possible about the
particular ethical dilemma to be decided.
Important data :
a. Patient’s wishes
b. Family’s wishes
c. Extent of the physical or emotional problems
causing the dilemma
 After collecting information, draw the pieces of
information together in a manner that gives the clearest
and sharpest focus to the dilemma.

74
The Five-Step Ethical Decision-Making Process
Step 2 : State the dilemma.
 Reduce the dilemma to a statement or two that revolves
around the key ethical issues.
 These ethical issues often involve a question of conflicting
rights or basic ethical principles.
Example: In a DNR order, the situation poses a question of
slow resuscitation or no resuscitation. The statement of the
dilemma might be: ‘The patient’s right to death versus the
nurse’s obligation.
Step 3: Consider the choices of action.
 List all the possible courses of action without considering the
consequences.
 Consequences of the different actions are considered later.
 Input from outside sources required, such as colleagues,
supervisors, or even experts in the ethical field.

75
Example of Options (same cited situation)
 Resuscitating the patient to the nurse’s fullest capabilities despite what
the physician has requested.
 Not resuscitating the patient at all, just going through the motions
without any real attempt to revive the patient
 Seeking another assignment to avoid dealing with the situation.
 Reporting the problem to a supervisor.
 Attempting to clarify the question with the patient.
 Attempting to clarify the question with the family.
 Confronting the physician about the question
Step 4. Analyze the Advantages and Disadvantages of
Each Course of Action
 By considering the advantages and the disadvantages, the nurse should
be able to pare the options down to the few realistic choices of action.
 Other relevant issues need to be examined while attempting to weigh
the choices of action.

76
The Five-Step Ethical Decision-Making Process
Step 5: Make the decision.
 The most difficult part of the process and ,as a corollary, living
with the consequences.
 By their nature, ethical dilemmas produce differences of
opinion.
 The best decision is one that is based on sound ethical
decision –making process.
 In resolving any ethical dilemma, questions will always remain
regarding the correct course of action.

77
 Caring and Nurse’s Narrative theory
 Nurse’s stories (REQUIREMENTS / PRESENTATION )
 The Nurse and the Lawsuit
 There is now a higher probability that a nurse, at some time in
his or her career, will be involved either as a witness or as a
party to a nurse malpractice action.
 Knowledge of the litigation process increases the nurses
understanding of the way in which the nurse’s conduct is
evaluated before the courts.
Prevention of Lawsuits for the Nurse
1. Maintain an accurate and complete medical record.
2. Establish rapport with the client through honest, open communication .
3. Keep one’s nursing knowledge and skills current to prevent errors that
may lead to lawsuits.
4. Recognizing the client who is a lawsuit-prone can help reduce the risk of
litigation.

Assignment
 Justice and principles in Allocation of Scare
Resources
 Right to die; Ethical dilemmas in Euthanasia
 Advanced Medical Directive: Durable power of
attorney for health care
 Caring and Nurse‟s Narrative theory and Nurse‟s
stories
78

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